Journal of Orthopaedic Science xxx (2018) 1e6

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Journal of Orthopaedic Science

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Original Article

Scapular muscles strengthening on pain, functional outcome and

muscle activity in chronic lateral epicondylalgia*
Kritika Sethi, Majumi M. Noohu*
Centre for Physiotherapy and Rehabilitation Sciences, Jamia Milllia Islamia, New Delhi, 110025 India

a r t i c l e i n f o a b s t r a c t

Article history: Aim: The aim of the study was to investigate the effect of lower trapezius (LT), middle trapezius (MT) and
Received 19 March 2018 serratus anterior (SA) strengthening on pain, pain free grip strength, functional outcome, scapular
Received in revised form muscles strength, scapular position and electromyographic (EMG) activity of lower trapezius, serratus
3 May 2018
anterior, extensor carpi radialis brevis (ECRB) and extensor digitorum communis (EDC) in individuals
Accepted 12 May 2018
Available online xxx
with chronic lateral epicondylalgia (LE).
Methods: Twenty six patients with chronic lateral epicondylalgia were recruited. Subjects were divided
into two groups. Group 1 received scapular muscles strengthening along with conventional physio-
therapy and Group 2 received only conventional physiotherapy for 6 weeks. Subjects were measured for
pain (VAS), pain free grip strength, functional outcome (PRTEE), scapular muscle strength, scapular
positioning (LSST) and EMG activity before and after the intervention.2
2 mixed ANOVA was used to
investigate for main effect of time and group and interaction effect (time
group).
Results: The results revealed that there was statistically significant difference for time effect for all the
outcome measures. In time
group interaction there was significant difference for all the outcome
measures except scapular position (LSST3). Significant difference for group effect was observed in EMG
activity of LT and ECRB.
Conclusion: The scapular muscle strengthening should be used along with the conventional physio-
therapy in individuals with chronic LE to improve pain, pain free grip strength, functional outcome,
muscle strength, scapular position and muscle activity.
© 2018 Published by Elsevier B.V. on behalf of The Japanese Orthopaedic Association.

1. Introduction need to screen and treat scapular muscle function deficits in in-
dividuals with LE.
Proximal stability is required for efficient functioning of distal No randomized control trial addressing the scapular muscles
segments in kinetic chain of upper limb [1]. Impairment of scapular weakness in chronic LE has been done till date. Also, there is no
musculature strength and endurance is noticed in individuals with evidence establishing a relationship between chronic LE and
lateral epicondylagia (LE) [2]. Lucado et al. found that there is altered scapular position due to impairment of scapular muscles.
diminished lower trapezius (LT) strength in female tennis players Thus the purpose of the study was to investigate the effect of
as compared to asymptomatic female tennis players [3]. Bhatt et al. scapular muscles strengthening on pain, pain free grip strength,
reported a case of improvement in pain, grip strength and func- functional outcome, muscle strength, scapular positioning and
tional disability on strengthening of middle and lower trapezius in muscle activity in individuals with chronic LE.
a patient with chronic LE [4]. A case series which deals with
management of LE by correcting scapular muscle deficits has 2. Methods
recently been reported [5].All these evidences points towards the
2.1. Subjects

*
The study was a repeated measure randomized experimental
Study approved by, Institutional ethical committee of Jamia Millia Islamia, New
Delhi, India.
design. A sample of convenience of 26 subjects with chronic lateral
* Corresponding author. Fax: þ91 11 2698 0229. LE were recruited from physiotherapy clinic of, Jamia Millia Islamia,
E-mail address: mnoohu@jmi.ac.in (M.M. Noohu). New Delhi for the study. The subjects were randomly allocated into

https://doi.org/10.1016/j.jos.2018.05.003
0949-2658/© 2018 Published by Elsevier B.V. on behalf of The Japanese Orthopaedic Association.

Please cite this article in press as: Sethi K, Noohu MM, Scapular muscles strengthening on pain, functional outcome and muscle activity in
chronic lateral epicondylalgia, Journal of Orthopaedic Science (2018), https://doi.org/10.1016/j.jos.2018.05.003
2 K. Sethi, M.M. Noohu / Journal of Orthopaedic Science xxx (2018) 1e6

one of the two groups (group 1 and group 2) through a computer the lateral humeral epicondyle [11], extensor carpi radialis brevis
generated random numbers. The sample size was calculated by (ECRB) stretching done with the elbow in extension, forearm in pro-
software G. Power 3.15 [6]. A total of 24 subjects were to be nation, and wrist in flexion and with ulnar deviation (6 times per
recruited to detect a 9 kg difference between the treatment groups session, 30e45 s hold with 30 s rest interval) and eccentric exercise for
in pain free grip strength at a level of 0.05 and power of 0.80 [7]. A wrist extensors done with the elbow supported in full extension,
15% drop out was expected and so the final number to be recruited forearm in pronation, wrist in extended position, and the hand
was 28. All the subjects completed the study protocol but 3 subjects hanging over the edge of the table. Subjects were asked to flex their
in group 1 missed 2 sessions and 2 subjects in group 2 missed 1 wrist slowly until full flexion was achieved and then returned to the
session of treatment respectively. Ethical clearance for the study starting position passively (3 sets
10 repetitions, 1 min rest interval
was approved by institutional ethics committee of Jamia Millia between each set, progressed by using Theraband [12]. Subjects un-
Islamia, New Delhi, India. derwent 3 sessions per week for 6 weeks.
The inclusion criteria were symptoms of LE from at least past 3
months, pain greater than 3 on VAS scale on the lateral epicondyle 2.5. Outcome measures
when palpated; pain in at least two of the following four tests,
Tomsen test, Maudsley test, Mill's test, handgrip dynamometer test 2.5.1. Pain
[8,9]. None of subjects participated in the study were consuming Pain was assessed using Visual Analogue Scale (VAS) which is
any oral medications such as NSAID's or using any other method for reliable tool to measure pain in patients with LE [13]. Subjects were
pain relief during the study period. Subjects were excluded if there asked to mark VAS scale based on the maximum pain they expe-
was, dysfunction in the shoulder, neck or thoracic region, local or rienced in the last 24 h.
generalized arthritis, local or generalized neurological deficit, radial
nerve entrapment, bilateral elbow pain, history of surgery in the 2.5.2. Pain free grip strength (PFG)
affected elbow, had undergone any treatment for LE in the past 4 It was measured in supine position with subject's arm by the
weeks. side, elbow extended and pronated using Jamar hand grip dyna-
mometer. Subjects were instructed to squeeze the dynamometer
2.2. Instruments handles until they experienced pain. It was performed three times
with 20 s rest period between repetitions [14]. Average of three
The instruments used in the study were, weighing machine, trials was recorded in kilograms. The measurement techniques
stadiometer, hand held dynamometer, hand Grip dynamometer, AD used in the study was reported to be valid and reliable [15].
instrument elab chart, therapeutic ultrasound (1mhz) unit,
Theraband (yellow, red and green) and measuring tape. 2.5.3. Patient rated tennis elbow evaluation questionnaire (PRTEE)
PRTEE has an excellent reliability and internal consistency.
2.3. Procedure Subjects were asked to rate the pain and difficulty that they have
experienced in the last week by marking the suitable response that
Subjects recruited filled up an informed consent form. They reflects their current state. The total score ranges from 0 to 100,
were explained the purpose, methods and rights as a participant in where high scores indicate greater pain and disability [16].
the study. They were selected based on inclusion criteria and
exclusion criteria. Subjects were assessed and baseline measures 2.5.4. Scapular muscle strength
were recorded on the day of recruitment. The process of assess- Lafayette hand held dynamometer (HHD) was used to record
ment and recording was completed in 60 min on an average. The force production of LT, MT and SA. HHD is a highly valid and reliable
treatment was started from the next day. Subjects in group 1 tool in measuring scapular muscle strength in shoulder pain patient
received supervised lower trapezius (LT), middle trapezius (MT)and [17]. For LT strength testing, the subject was placed in prone lying
serratus anterior (SA) strengthening along with conventional position with elbow in extension and shoulder in 140 abduction.
physiotherapy and in group 2 subjects received only conventional The therapist stood on the opposite side and with his elbow
physiotherapy. Each treatment session lasted for 40e45 min. Both straight applied the resistance force from HHD on the spine of
groups received treatment for 3 days a week for a total duration of scapula in superior and lateral direction parallel to the long axis of
six weeks. After completion of the treatment protocol, subjects humerus. For MT strength testing, the subject was placed in prone
were reassessed and outcome measures were recorded on the next lying position with elbow in flexion and shoulder placed at 90
day. Subjects were instructed to keep away from activities that abduction. The therapist stood on the opposite side and with his
aggravated the symptoms such as grasping, lifting, knitting, driving elbow straight applied the resistance force from HHD on the spine
car and using screwdriver during the course of the study. The of scapula in lateral direction parallel to long axis of humerus. For
assessment and treatment was done by two different therapists SA strength testing, the subject was placed in supine lying position
who were having no information about the study protocol. with shoulder and elbow flexed to 90 . The therapist stood on the
same side and resistance was applied at the olecranon process
2.4. Intervention along the long axis of the humerus. Each muscle strength test
was performed three times and their average was recorded in
2.4.1. Scapular muscle strengthening Newton [17].
The patients in group 1 received scapular muscle strengthening
exercises along with conventional physiotherapy for 6 weeks. The 2.5.5. Scapular position
exercises are described in Table 1 [10]. To measure static scapular positions lateral scapular slide test
(LSST) was used. LSST had shown good test-retest and inter tester
2.4.2. Conventional treatment reliability [18]. For test position 1 of the LSST 1, the subjects were
Conventional treatment was received by both the groups and it asked to keep their upper extremities in neutral position. For test
included pulsed ultrasound (20% duty cycle, 71/2 min,1 MHZ, 2w/cm2) position 2 (LSST 2), the subjects were asked to place both hands on
given for 3 sessions during the first week, 2 sessions during the second the ipsilateral hips, placing upper extremities in medial rotation at
week, and 1 session per week during the remaining 4 weeks around 45 of abduction. In test position 3 (LSST 3), the subjects were asked

Please cite this article in press as: Sethi K, Noohu MM, Scapular muscles strengthening on pain, functional outcome and muscle activity in
chronic lateral epicondylalgia, Journal of Orthopaedic Science (2018), https://doi.org/10.1016/j.jos.2018.05.003
 K. Sethi, M.M. Noohu / Journal of Orthopaedic Science xxx (2018) 1e6 3

Table 1
Summary of scapular muscles strengthening protocol.

Muscle Exercise Dosage Progression

Lower Trapezius 1. Arm raise above the head with Frequency: 3 times per week. 1. By increasing number
upper extremity in line with lower Intensity: 3 sets of 10 repetitions of repetitions until the patients
trapezius muscle fibers in prone position Duration: 6 weeks were able to perform 3 sets of
2. Shoulder horizontal extension with 10 repetitions
external rotation in prone position [10] 2. Further progression was done
Middle Trapezius 1. Unilateral row using theraband.
2. Shoulder external rotation with the Therabands were progressed
shoulder abducted 90 abd elbow according to the color coding
flexed 90 in prone position with which is based on the resistance
elbow supported on the table [10] they provide.
Serratus Anterior 1. Shoulder abduction in plane of Yellow to red to green
scapula above 120 in standing position
2. Diagonal exercise with a
combination of shoulder flexion,
horizontal flexion and external
rotation in sitting position [10]

to extend both elbows and to elevate and maximally internally was performed 3 times and EMG activity was recorded. Average of
rotate both upper extremities to 90 .The distance between the the readings was used for calculating % MVIC.
inferior angle of the scapula and the closest spinous process in the Following the above procedure % MVIC was calculated for LT, SA,
same horizontal plane were measured bilaterally using an inch tape EDC and ECRB using the formula:
and the difference between the bilateral distances was recorded for
all the three positions [18]. Muscle activity  100
%MVIC ¼
MVIC of the muscle
2.5.6. Electromyography (EMG)
EMG data were collected for LT, SA, ECRB and extensor digiti
communis (EDC) muscles prior to and after the completion of the 2.6. Data analysis
intervention. Maximal voluntary isometric contraction (MVIC) for
each muscle was recorded for normalization purpose. Skin prepara- Data analysis was done using software SPSS version 21.0 and the
tion was done prior to the EMG recording to reduce impedance by statistical significance was set at p  0.05. The demographic charac-
shaving hair and rubbing skin with abrasive and alcohol swabs. For LT teristics were compared between the both groups at the study entry
and SA, bipolar surface electrode was placed with a 1 cm interelec- by an independent t-test. 2
2 mixed ANOVA was employed to test
trode distance. The lower trapezius electrode was placed upward and for main effect for time and group and interaction effect (time

laterally along a line between the intersection of the spine of the group) for all the outcome measures with intention to treat analysis.
scapula with the vertebral border of the scapula and the seventh
thoracic spinous process.The serratus anterior electrode was placed 3. Results
at insertion of the muscle on the anterio-lateral side of the thorax
over the 7th rib in the anterior axillary line. A reference electrode was The characteristic features of the sample (n ¼ 26) is given in the
placed over the clavicle for LT and SA activity [19]. For ECRB and EDC, descriptive statistics in Table 2. The mean ± SD of pre and post
electrodes were placed with 2 cm interelectrode distance on the intervention of pain, pain free grip strength, PRTEE, scapular posi-
thickest part of the muscle belly and reference electrode was placed tion, scapular muscle strength and %MVIC is tabulated in Table 3.
just above the elbow on upper arm for ECRB activity [20]. There was statistically significant main effect for time for pain
For recording MVIC of muscles to be tested, isometric con- (p ¼ 0.001), pain free grip strength (p ¼ 0.001), functional outcome
tractions in manual muscle test positions were performed. For LT (p ¼ 0.001), LT, MT and SA strength (p ¼ 0.001), scapular position
and SA the position for MVIC measurement was same as LSST1 (p ¼ 0.003), LSST2 (p ¼ 0.001), LSST3 (p ¼ 0.003) and% MVIC
described in scapular muscle strength measurement. Three of LT (p ¼ 0.001), % MVIC of SA (p ¼ 0.008), % MVIC of EDC
readings of 5 s maximum voluntary isometric muscle contrac- (p ¼ 0.001), % MVIC of ECRB (p ¼ 0.001) [Table 4].
tions against manual resistance were recorded with a 5s pause There was statistically significant group effect for % MVIC of LT
between repetitions. For ECRB MVIC measurement, the subjects (p¼0.03) and ECRB (p¼0.02). But there was no statistically signifi-
were asked to extend the wrist towards the radial side maximally cant difference in group effect for pain (p ¼ 0.09), pain free grip
against manual resistance and for EDC, the subjects were asked strength (p ¼ 0.56), functional outcome (p ¼ 0.95), LT strength
to extend the metacarpaophalangeal joints maximally against
resistance keeping interphalangeal joints relaxed. Three readings
Table 2
of 2e3s hold were recorded with 1 min pause between the Comparison of demographic characteristics between groups.
repetitions [20]. Average of the repetitions was used for
Variable Group 1 (n ¼ 13) Group 2 (n ¼ 13) t p
normalization value.
mean ± SD mean ± SD
Following normalization, specific activities for LT, SA, ECRB and
Age (years) 44.92 ± 10.84 47.77 ± 9.44  0.71 0.37
EDC were performed to record the muscle activity. For recording LT
Height (cm) 161.46 ± 7.10 165.12 ± 10.33 0.79 0.96
and SA muscle activity, shoulder abduction in the plane of the Weight (kg) 65.81 ± 7.78 67.99 ± 9.29 1.05 0.30
scapula above 120 was performed [10]. For recording ECRB and BMI 26.17 ± 3.19 25.13 ± 3.53 0.79 0.91
EDC muscle activity, gripping was done at 20% maximal grip Duration (months) 5.3 ± 2.49 4.46 ± 1.66 1.02 0.32
strength of asymptomatic side, with wrist extended and forearm in BMI: body mass index; Group 1: males ¼ 6, females ¼ 7; Group 2: males ¼ 7,
pronation [21]. After practicing for a few repetitions, each activity females ¼ 6; significant difference ¼<0.05.

Please cite this article in press as: Sethi K, Noohu MM, Scapular muscles strengthening on pain, functional outcome and muscle activity in
chronic lateral epicondylalgia, Journal of Orthopaedic Science (2018), https://doi.org/10.1016/j.jos.2018.05.003
4 K. Sethi, M.M. Noohu / Journal of Orthopaedic Science xxx (2018) 1e6

Table 3
Comparison of mean ± SD of outcome measures for both groups before and after intervention.

Variable Group 1 mean ± SD Group 2 mean ± SD

Pre Post Pre Post

Pain (VAS) 6.92 ± 1.38 2 ± 0.816 6.77 ± 1.58 3.62 ± 1.19

PFG (kg) 5.01 ± 2.81 14.34 ± 4.01 6.28 ± 4.21 11.32 ± 4.92
PRTEE 50.14 ± 15.38 18.11 ± 6.48 44.76 ± 12.71 23.91 ± 7.92
LSST1 (cm) 0.88 ± 0.56 0.54 ± 0.33 0.73 ± 0.54 0.69 ± 0.48
LSST2 (cm) 1.36 ± 0.62 0.83 ± 0.53 1.18 ± 0.75 1.06 ± 0.64
LSST3 (cm) 0.81 ± 0.51 0.61 ± 0.40 0.96 ± 0.47 0.81 ± 0.51
LT strength (N) 126.38 ± 31.33 187.66 ± 38.80 130.14 ± 39.53 137.51 ± 32.20
MT strength (N) 116.15 ± 28.49 168.52 ± 35.47 128.25 ± 37.38 135.88 ± 28.35
SA strength (N) 145.26 ± 43.20 209.71 ± 29.12 147.66 ± 45.29 154.66 ± 36.85
% MVIC LT 49.65 ± 12.09 75.79 ± 12.32 48.69 ± 18.12 52.47 ± 14.25
% MVIC SA 76.22 ± 44.58 124.70 ± 106.48 64.52 ± 23.36 68.6 ± 31.43
% MVIC EDC 79.43 ± 11.64 53.43 ± 12.03 75.09 ± 15.02 57.39 ± 12.09
% MVIC ECRB 52.03 ± 13.05 81.20 ± 16.55 44.8 ± 14.94 61.62 ± 15.24

PFG: Pain Free Grip Strength, PRTEE: Patient Rated Tennis Elbow Evaluation, LSST: Lateral Scapular Slide Test, LT: Lower Trapezius, MT: Middle Trapezius, SA: Serratus
Anterior, MVIC: Maximum Voluntary Isometric Contraction, EDC: Extensor Digitorum Communis, ECRB: Extensor Carpi Radialis Brevis.

(p ¼ 0.09), MT strength (p ¼ 0.41), SA strength (p ¼ 0.08), scapular There can be four plausible mechanisms that explain the link
positioning LSST1 (p ¼ 1), LSST2 (p ¼ 0.92), LSST3 (p ¼ 0.34) and % between scapular muscles weakness and chronic LE. Firstly, a firm
MVIC of SA (p ¼ 0.14), % MVIC of EDC (p ¼ 0.96) [Table 4]. base is required for the efficient use of the distal segments in a
There was statistically significant interaction effect (time X kinetic chain. The main stabilizers of the scapula are trapezius and
group) for pain (p ¼ 0.004), pain free grip strength (p ¼ 0.001), serratus anterior muscles. If the scapula is not stable because of the
functional outcome (p ¼ 0.03), LT, MT and SA strength (p ¼ 0.001), weakness in surrounding musculature, it will alter length tension
scapular positioning LSST1 (p ¼ 0.02), LSST2 (p ¼ 0.007) and % MVIC relationship of rotator cuff muscles which will further place
of LT (p ¼ 0.001), % MVIC of SA (p ¼ 0.02), % MVIC of EDC (p ¼ 0.06), increased energy demands on tissues of elbow and wrist, predis-
% MVIC of ECRB (p ¼ 0.02). There was no statistically significant posing them to overuse injury [1]. This chain of events can occur in
difference in scapular positioning LSST3 (p ¼ 0.66) [Table 4]. opposite direction too. In chronic LE, in order to avoid pain, the
individual uses the upper extremity in a protective and guarded
4. Discussion manner during functional activity, which will decrease the range of
motion of shoulder and alter rotator cuff functioning and over a
The purpose of the study was to investigate the effect of scapular period of time it can lead to scapular muscles weakness [22,23].
muscles strengthening on pain, pain free grip strength, functional Secondly, as individuals with chronic LE avoid pain aggravating
outcome, muscle strength, scapular position and electromyo- activities, there is decreased use of forearm muscles which results
graphic activity in individuals with chronic LE. The results obtained in decreased activation of trapezius and serratus anterior. This
revealed that there was significant difference in all the out mea- connection can be attributed to the reflex connection from forearm
sures for time effect, significant difference for group effect in EMG afferents to LT and SA which provide proximal stabilization with
activity of LT and ECRB, and significant difference in time
group task involving forearm and hand muscles [24].
interaction for all the outcome measures except LSST3. The results Thirdly, there are evidences which indicate that there are
for pain, pain free grip strength, functional outcome, scapular myofascial and myotendinous pathways that help in force trans-
muscle strength and scapular positioning are in accordance with a mission from distal to proximal located areas in upper extremity
case report, where strengthening of lower trapezius and middle resulting in proximal stability [25]. In chronic LE, there can be
trapezius muscles in a patient with chronic LE resulted in alteration in this mechanism of force transmission resulting in
improvement in all these outcome measures [4]. There is no evi- weakness of proximal stabilizers over a period of time.
dence available that investigated the effect of scapular muscles Finally, because of pain in chronic LE there can be alterations in
strengthening on EMG activity of ECRB and EDC. central mechanism which can be a reason for the muscle weakness.

Table 4
Summary of mixed model analysis of variance.

Variables Main effect (time) Main effect (group) Interaction (time
group)

p Partial eta squared (effect size) p Partial eta squared (effect size) p Partial eta squared (effect size)

Pain (VAS) 0.001 0.9 0.09 0.11 0.004 0.29

Pain free grip strength (kg) 0.001 0.86 0.56 0.01 0.001 0.36
PRTEE 0.001 0.83 0.95 0.001 0.03 0.18
LSST1 (cm) 0.003 0.31 1 0.001 0.02 0.21
LSST2 (cm) 0.001 0.46 0.92 0.001 0.007 0.26
LSST3 (cm) 0.003 0.30 0.34 0.04 0.66 0.01
LT strength (N) 0.001 0.68 0.09 0.11 0.001 0.57
MT strength (N) 0.001 0.8 0.41 0.03 0.001 0.68
SA strength (N) 0.001 0.69 0.08 0.12 0.001 0.59
% MVIC LT 0.001 0.74 0.03 0.18 0.001 0.62
% MVIC SA 0.008 0.26 0.14 0.09 0.02 0.2
% MVIC EDC 0.001 0.81 0.96 0.001 0.06 0.14
% MVIC ECRB 0.001 0.78 0.02 0.21 0.02 0.21

Please cite this article in press as: Sethi K, Noohu MM, Scapular muscles strengthening on pain, functional outcome and muscle activity in
chronic lateral epicondylalgia, Journal of Orthopaedic Science (2018), https://doi.org/10.1016/j.jos.2018.05.003
 K. Sethi, M.M. Noohu / Journal of Orthopaedic Science xxx (2018) 1e6 5

Muscle weakness by regional muscle pain is reported in quadriceps Acknowledgments

muscle [26]. In spite of all the possible mechanism that explains the
connection between scapular muscle weakness and chronic LE We would like to extend our thanks to Prof. Ejaz M. Hussain,
there is no study till date that could establish a definitive cause or Director, Centre for Physiotherapy and Jamia Millia Islamia, New
effect relationship between scapular muscles weakness and Delhi and the Vice Chancellor of Jamia Millia Islamia, New Delhi for
chronic LE. However, correcting the weakness which could be the support.
because of any of the above explained mechanism by scapular
muscles strengthening will result in a better and comprehensive
rehabilitation of individuals with chronic LE, which is consistent References
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chronic lateral epicondylalgia, Journal of Orthopaedic Science (2018), https://doi.org/10.1016/j.jos.2018.05.003
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Please cite this article in press as: Sethi K, Noohu MM, Scapular muscles strengthening on pain, functional outcome and muscle activity in
chronic lateral epicondylalgia, Journal of Orthopaedic Science (2018), https://doi.org/10.1016/j.jos.2018.05.003